The Problem. More than 30 percent of American children are either overweight or obese. Childhood obesity is associated with increased risk of health problems and with obesity and chronic disease during adulthood. School-based obesity prevention efforts, which occur mostly during school hours, have produced only modest results, so some health experts have turned their attention to programs that occur during out-of-school time (OST), which may have the potential to address childhood obesity. More than 8 million children participate in such programs every year, often attending 15 or more hours per week during the school year and all day during the summer. Most OST programs provide at least one snack or meal and strive to model positive behavior, according to the National AfterSchool Association. With guidelines for OST programs in varying stages of development, more information was needed to understand how programs address physical activity and healthy eating, and what stands in the way of good practices.
RWJF Approach. Robert Wood Johnson Foundation (RWJF) has supported several initiatives aimed at reversing the childhood obesity epidemic. Its Active Living Research and Healthy Eating Research programs stimulate and support research to examine environmental factors and policies that influence physical activity and eating. Funded researchers use a transdisciplinary approach—one that encourages experts from various disciplines to collaborate on identifying environmental factors and policies that are related to physical activity and nutrition. Both programs place special emphasis on children of color and lower-income children, who are at greater risk for obesity. See Program Results for more information on Active Living Research and a Progress Report for more information on Healthy Eating Research.
Georgia Hall Takes Advantage of Title IX. Georgia Hall was just beginning junior high school when the U.S. Congress enacted Title IX in 1972. This legislation prohibited sex discrimination in education and opened the door to equal opportunities in high school and college athletics for girls and young women. The timing couldn't have been better. Hall, who played softball and basketball, went to a school with an excellent sports program. As long as she could remember, her father—a former standout in college baseball—had coached in the youth leagues for their Long Island, N.Y., community, and Hall and her brother both participated in sports programs after school and on Saturdays.
"I grew up in a family that placed great value on sports, athletics, and physical activity," Hall notes. And, in the broader ethos, "the culture was changing around supporting girls and women in sports. It was an encouraging time to be interested in sports and athletics."
After earning a BA in English from Duke University, Hall worked for youth development organizations as a camp counselor, Sunday school teacher, and summer program volunteer. She returned to academia to earn an MA from Clark University and PhD from Boston College, both in education.
"All of those early experiences combined to bring me to a point in my research where I'm very interested in the connection between youth development and youth physical activity," says Hall, now a senior research scientist at the National Institute on Out-of-School Time (NIOST) at Wellesley College. "Our focus is on what youth are doing when they're not sitting in the classroom, and it's about all of the things that contribute to their healthy development and wellness. We're trying to do what we can to turn that information and learning back to the field."
Studying Physical Activity and Healthy Foods in OST Programs. In January 2010, Hall received funding from Active Living Research and Healthy Eating Research for a one-year project to (1) conduct a baseline study of physical activity and healthy eating practices and policies in a national sample of OST programs, and (2) infuse more rigorous content and language into the physical activity and healthy eating sections of standards for afterschool programs promulgated by the National AfterSchool Association.
Hall and her colleague, Jean L. Wiecha, PhD, led a research team that interviewed 17 people around the country who occupy key administrative positions at government agencies and independent organizations that support OST programming and learning. They asked interviewees:
- Where do childhood obesity, physical activity, and healthy eating fit into the agenda and priorities for OST programs in your community, city, region, or network of organizations?
- What are the barriers that OST programs face in creating more time for physical activity and healthier eating?
- What standards and guidelines do the programs use, and would more rigorous and specific guidelines be likely to improve practices?
- What supports (e.g., management, staffing, guidelines, communication, training, financial resources, other infrastructure) need to be in place or would have to change to support more physical activity and healthier eating practices?
The researchers also conducted an online survey of more than 700 OST program directors in 12 cities to learn about key characteristics of their programs, such as staff training, supervision, program planning, enrollment, organizational structure, standards and accreditation status, and support mechanisms. Their analysis focused on 493 completed surveys.
Hall also worked with the National AfterSchool Association and a coalition of advisory organizations facilitated by it to compile a set of standards for physical activity and healthy eating in OST programs. The association adopted the standards in April 2011 and now plays a role in disseminating them and encouraging implementation.
In addition, Hall and her colleagues published one paper on the healthy eating portion of the study in the Spring 2012 issue of the Afterschool Matters Journal, with another article, scheduled to appear in Childhood Obesity in December 2012. The research team also gathered and posted relevant resources from web links, local and regional standards and guidelines, and relevant news articles on the association's website.
Findings About Physical Activity and Food. Hall found that the OST program directors and administrators she interviewed were very concerned about childhood obesity, and they identified physical activity and healthy eating as important components of their work.
- Some 80 percent of the OST program directors who responded to the survey said they offered physical activity for all students, and more than half (55%) made it mandatory.
- The amount of physical activity varied from 30 to 60 minutes (at 61% of programs) to more than an hour (30% of programs).
- In most programs (85%), most or all of the youth participated in the physical activity, and at 75 percent of programs at least two staff also participated.
- About 68% percent reported using some type of guidelines for physical activity.
- Having infrastructure for physical activity did not necessarily translate into good practice.
- Positive relationships among students and staff, strong group management, and the presence of engaging staff played a more critical role than infrastructure in ensuring that physical activities were delivered effectively.
On the food front:
- Most program directors agreed that clear, consistent food and beverage guidelines are desirable but the guidelines they used varied—and so did the quality of the snacks they served.
- A sizable minority (31%) reported not using any guidelines for nutritional health.
- Although fruits and vegetables were the most commonly reported class of foods served, only 49 percent of program directors indicated that their programs had served those foods recently (i.e., the day before the survey).
Findings About Barriers to Healthy Food and Physical Activity. Through the survey and the interviews, Hall discovered many barriers to providing physical activity and healthy food in OST programs.
- Some program directors wanted to serve healthy foods but could not get them, either because of the cost or because food was delivered by the school system and the OST director did not think he or she could influence the menu.
- Programs that purchased their own food had more choice but some faced difficulties with devoting staff time to shopping.
- OST programs that did not have shared-use agreements with schools sometimes had trouble accessing refrigeration for storing fresh fruits and vegetables.
- Finding space to move around was an issue, especially for programs with low funding levels.
- Other issues included the costs related to equipment, motivating children to be active, and getting staff to be active with the children.
- The need to create a culture of activity among both children and staff. "There's a sense among some directors that ‘If I just throw a ball out, my kids are going to be physically active,'" Hall says. "There will always be some kids who pick up that ball and play for 20 minutes straight, but if there's no adult intervention and enthusiasm for being physically active, it's probably not going to be 100 percent of the kids. There might be some who are just walking around the playground, or sitting, or not engaging—and it might be the 20 percent who most need to be active who aren't."
- Physical activity during out-of-school time has to compete for time and attention with efforts to help children improve academically. "Afterschool programs are under huge pressure to provide homework help and tutoring, so where does physical activity fit in? For some families, it may not seem like a priority. So part of the challenge for afterschool program leaders is to help parents understand how important it is to fit physical activity into the day," Hall says.
Policy Implications. Hall sees widespread interest in the topic of healthy food and physical activity during out-of-school time, with many people working to find the best avenues to making a positive impact on children and youth. Her research suggests what some of those avenues might be. For instance:
- The majority of programs in Hall's survey are operated by just a few private nonprofit organizations, so policy efforts that target large providers (e.g., the national YMCA, 21st Century Community Learning Centers, Boys and Girls Clubs) might be effective.
- Relationships between OST programs and public schools are ripe for policy influence because they affect how space and resources are shared. (More than three-quarters of programs in the study were located in schools, although many were operated by other agencies.)
- The knowledge that physically active staff who can engage youth in activities are a key to students' physical activity, means that staff training becomes an important focus for improvement.
- Activities may need to be adjusted so that all types of children and youth can participate. To increase activity among children who have physical challenges, it may be necessary to change the dynamics of play and the space available to ensure 100 percent participation.
Looking Ahead. After the RWJF study ended, Hall obtained funding from the Centers for Disease Control and Prevention (CDC) to evaluate After School Gets Moving, a project of Vida Health Communications that provides training to after-school providers on how to promote physical activity among children ages 6–10. Results from that study indicate that training can increase staff knowledge, create excitement about physical activity, and help to create a culture of physical activity in ways that increase the students' level of physical activity, Hall says.
Hall also participated in a two-year evaluation of Build Our Kids' Success (BOKS), a before-school physical activity program funded by the Reebok Foundation, and is preparing to disseminate findings from that study. And she hopes to continue working on the implementation of standards for healthy eating in OST programs.
Meanwhile, Hall is passing on her family's tradition of physical activity to the next generation. Having finished coaching her older daughter's softball and basketball teams, which she did for 10 years, she's well entrenched this year, the 40th anniversary of Title IX, in coaching second-grade and pre-school soccer for her youngest children—along with serving healthy snacks.
RWJF Perspective. Launched in 2000, Active Living Research is a $31 million national program that supports research to examine how physical and built environments and policies influence the amount of physical activity Americans get as part of everyday life. Findings from the research are used to help inform policy, the design of the built environment and other factors necessary to reengineer healthy levels of physical activity into everyday life for all Americans. Over the past few years, the program has focused on reversing the rise in childhood obesity, particularly in the lower-income and racial/ethnic minority communities in which childhood obesity levels are highest and rising fastest.
A recent analysis by Program Director James Sallis, PhD, documents dramatic growth in research to identify policy and environmental factors and interventions affecting physical activity at the population level and in high-risk populations following the program's launch in 2001.
Active Living Research teams are required to be transdisciplinary, involving investigators from multiple disciplines and backgrounds who work together across traditional disciplinary boundaries. The researchers represent more than 20 different disciplines (e.g., public health, urban planning, architecture, behavioral science, exercise science, transportation, sociology, and political science). "In addition to building an evidence base to guide physical activity policy and community design, Active Living Research is developing a vibrant, new transdisciplinary field and diverse network of researchers," says C. Tracy Orleans, PhD, RWJF distinguished fellow and senior scientist.
Active Living Research actively seeks to translate research findings rapidly into policy and practice change. Says Orleans: "For instance, if we find out that adding bike paths and sidewalks or walk-to-school programs significantly increases physical activity, we want to get this information out to key decision- and policy-makers as quickly and effectively as possible, so they can start using it."
Orleans adds, "The Active Living Research program has sparked new awareness among policy-makers and community leaders in many sectors that how active we are depends greatly on the built environment and on the presence or absence of environmental and policy supports for physical activity. In addition, a growing number of urban planners and transportation policy-makers recognize that community design is critical for health."
68% of out-of-school time programs used guidelines for physical activity; 31% used none for nutritional health.